Nonadherence to prescribed medication is a major problem in the management of chronic disease. Estimates are that about 40 percent to 60 percent of patients adhere with the costs of nonadherence approaching 10 billion dollars per year. Yet very few randomized, controlled intervention trials have been conducted to guide efforts to improve adherence. The disease represented in the limited number of intervention studies include asthma, hypertension, epilepsy, schizophrenia and acute infection. No studies, other than our own, have been done with patients with rheumatoid arthritis (RA). The adherence rates for persons with RA are equivalent to those found for other chronic disorders. Adherence is particularly important for this population, as pharmacological treatment is directed toward the suppression of inflammation and resulting synovitis and the prevention of disability. In a recently completed study, we conducted a randomized, controlled intervention study of a behaviorally based, 12- session, telephone counseling intervention on adherence. We found differences in adherence between an intervention and usual care group of 12.3 percentage points (z=minus 1.91, p is less than or equal to .03) with changes in adherence associated with changes in pain (rs=minus.29, p is less than or equal to .01). Although promising, differences in adherence at six month follow-up were not statistically significant (p is less than or equal to .07). In this project we propose to replicate our intervention study using telephone counseling as well as to examine a less costly method of intervention delivery, mailed self-instruction, and further to examine the efficacy of an ongoing maintenance strategy on adherence, clinical outcomes, and cost-effectiveness. Specifically our aims are to (1) compare the effect of telephone delivered intervention, mailed self-instruction, and usual care on adherence to pharmacological therapy, clinical outcomes, and cost-effectiveness as well as to (2) compare the effect of an adherence intervention plus maintenance intervention with adherence followed by observation only and usual care on adherence to pharmacological therapy, clinical outcome, and cost-effectiveness. We propose to recruit from two practice sites and randomize 198 persons with rheumatoid arthritis who report some difficultly with the medication regimen. Using a randomized, controlled design, patients would be randomized into telephone intervention, mailed self-instructional intervention, or usual care for a six month intervention period. Following the intervention phase, the two intervention groups would be randomized within groups to maintenance intervention or observation only for an additional six months. The usual care group would continue to be followed to generate natural history data for comparison purposes. Should one or more of the strategies prove successful, intervention manuals would be disseminated for use by nurses working in clinical settings with this population.